Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 202 of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information could prevent us from making an accurate and timely decision on your claim for
benefits.
We will use this information to determine your eligibility for reduced benefits as a widow(er) or
a surviving divorced spouse. We may also share the information for the following purpose,
called routine uses:
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To third party contacts where necessary to establish or verify information provided by
representative payees or applicants; and
To contractors and other Federal agencies, as necessary, for the purpose of assisting
Social Security Administration in the efficient administration of its programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784. Additional information, and a full listing of all of our SORNs, is
available on our website at www.ssa.gov/privacy.